Make serious incidents a learning opportunity
Set up serious-incident committees
It can happen at any hospital: A post-surgical patient is receiving narcotics and therapy for pain control. The respiratory therapist leaves the patient's bed rails down, and the groggy patient falls from the bed. A nurse finds the patient on the floor and calls the doctor. The doctor does not believe the fall is serious and does not examine the patient. The patient dies the next day.
This is a serious incident that any hospital would fear. Many hospitals might be prone to put the accident behind them as soon as possible. But instead of trying to put it behind you, learn from it. Risk management experts say serious-incident committees can be a valuable tool for education and quality improvement.
"When you have an adverse event, the system failed in some way. We think it is imperative to look at system issues," says Vickey Masta-Gornic, director of risk management for Albany (NY) Medical Center Hospital. "We pull together representatives from the departments involved to look at the system issues in a timely fashion, to make sure no policies conflict within departments or conflict with practices. There could be a million little things that no one has looked at the details of for awhile. One little change can create a cascade."
At Tampa (FL) General Hospital, Director of Risk Management Paula Bradlee, RN, CHRM, forms multidisciplinary serious-incident committees to review and learn from adverse incidents like the one in the above hypothetical scenario. The committees there do not have an investigative or disciplinary function. Instead, they serve to help her spot areas where existing policies are lacking or are in conflict with other departments.
She says the committees also have engendered a new degree of respect for the risk management department from the rest of the hospital staff. "We've had a number of them in the last year, and we are surprised how successful they've been. People walk out thinking it was a good idea that we got together," Bradlee says.
Form one early
Risk managers in states with mandatory adverse incident reporting say they often use the statutory requirements as a guide for when to form a serious-incident committee. Tampa General's Bradlee uses the Florida requirements as a threshold standard for when to convene a committee. But she also advises risk managers to consider forming one when adverse incidents occur in which several departments are involved, where delays in treatment occurred, or where there are bad obstetrical outcomes.
The committee should meet as soon after the incident as possible, risk managers advise. Masta-Gornic tries to convene a serious committee within 24 hours of the incident in order to keep the events fresh in everyone's mind. But others advise risk managers to wait until any internal investigations are completed to have the hospital's report available.
Risk managers differ over whether the actual participants or their supervisors should be included on the committee. Gornic espouses using supervisors or designates from the departments involved. "It's too hard because [the participants] are too close to the event. We have had successful teams with the staff representatives because they understand the practices."
George Foley, CHRM, director of risk management for University Community Hospital in Tampa, FL, says clinical representatives should be included on the committee to gain a diversity of perspectives. "It also eases some of the scrutiny between the clinical and nonclinical staffs if both are included."
Depending on the incident, risk managers may want to include representatives from hospital administration and quality assurance. They caution risk managers to play a facilitative role, not an investigative one, during the committees. They stress that these committees are set up as a learning tool.
Don't point fingers
Once the committee is convened, Bradlee says it is imperative that discussions about fault are excluded. "The most important thing is to begin the committee by explaining to members the purpose of the committee: No one is there to point fingers or do anything other than identify where we went wrong and how we can improve. Give a speech at the beginning about the fact that we are humans and make mistakes. It's only a problem if the mistakes don't get corrected," she says.
Bucky Jones, RN, clinical risk manager at Tampa General advises risk managers to try to keep money issues out of the committee room. She says any talk of lawsuits diverts the participants' attention from the real purpose.
All proceedings should be kept confidential. Jones advises risk managers to tell the participants that nothing said inside the committee room is allowed to leave there. Confidentiality also will encourage people to speak freely.
Risk managers also are advised to check with their legal counsel about the discoverability of a committee's proceedings. Some states have broad discovery laws which could allow the minutes of the meeting to be used against the hospital in a lawsuit. Lawyers can advise how to set up the minutes to keep them insulated from discovery.
Bradlee says the key to these meetings is free flow of information from as many of the people involved in the incident as possible. Still, some will be hesitant to attend. She advises other risk managers to try to encourage those who are hesitating by offering to reschedule the meeting around their schedule. But if they do not want to attend, do not force the issue. "If they do not want to talk, all you can do is bring it up at an administrative claims committee." *
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